MEDICAL FORM

Before any medication is dispensed to my child, I will provide a written authorization, which includes: Date, Name of Child, Name of Medication, Prescription Number (if any), Dosages, and Date and Time of Day to be given to child. Medicine will be in the original container with my child’s name marked on it.
My child will not be allowed to enter or leave the facility without being escorted by the parent(s), person(s) authorized by parent(s), or facility personnel.
I acknowledge it is my responsibility to keep my child's records current to reflect any significant changes as they occur, e.g., telephone numbers, work location, emergency contacts, child's physician, child's health status, infant feeding plans, and immunization records, etc. The facility agrees to keep me informed of any incidents, including illnesses, injuries, adverse reactions to medications, etc., which include my child.
Kaleidoscope Montessori agrees to obtain written authorization from me before my child participates in routine transportation, field trips, special activities away from the facility, and water-related activities occurring in water that is more than two (2) feet deep. I authorize the child care facility to obtain emergency medical care for my child when I'm not available. I have received a copy and agree to abide by the policies and procedures for Kaleidoscope Montessori.

Guardian's Signature *
Guardian's Signature
Date
Date
EMERGENCY CONTACTS
In an emergency, if neither guardian can be reached, please try to reach the following people:
1. Name *
1. Name
Address
Address
Telephone Number *
Telephone Number
Secondary Telephone Number
Secondary Telephone Number
2. Name *
2. Name
Address
Address
Telephone Number *
Telephone Number
Secondary Telephone Number
Secondary Telephone Number
Address
Address
Telephone Number *
Telephone Number
Secondary Telephone Number
Secondary Telephone Number
MEDICAL INFORMATION
Telephone Number of Pediatrician
Telephone Number of Pediatrician